Nokea
A client with heart failure (HF) returns to the clinic two weeks after adjustments were made to the prescribed cardiac glycoside, diuretic, and potassium supplement. The client's lungs are clear, heart rate is 58 beats/minute, and serum potassium level is 2.9 mEq/L (2.9 mmol/L). Which action is most important for the nurse to implement?
- A. Compare the weight with what it was at last visit.
- B. Report serum potassium to healthcare provider.
- C. Review the dietary history from the past week.
- D. Check the pretibial areas and ankles for edema.
Correct Answer: B
Rationale: Reporting hypokalemia (2.9 mEq/L) is critical to prevent arrhythmias, especially with cardiac glycosides.
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The nurse is collecting a urine specimen for a client with symptoms related to urethritis. Which collection method should the nurse implement?
- A. First voided specimen in the morning.
- B. A clean catch specimen.
- C. Any specimen voided after drinking adequate fluids.
- D. A 24-hour specimen.
Correct Answer: B
Rationale: A clean catch specimen minimizes contamination, providing accurate results for diagnosing urethritis, unlike other methods.
The nurse reviews discharge instructions with a client who has gastroesophageal reflux disease (GERD). Which instruction is most important for the nurse to emphasize?
- A. Minimize intake of spicy foods.
- B. Remain upright following meals.
- C. Avoid wearing tight fitting clothes.
- D. Begin a smoking cessation program.
Correct Answer: B
Rationale: Remaining upright after meals prevents acid reflux by facilitating digestion, making it the most critical instruction for GERD management.
An older adult client, at risk for osteoporosis, reports taking a multivitamin daily. In developing a teaching plan for the client, which follow- up Information should the nurse obtain?
- A. What time of day the multivitamin is taken.
- B. The amount of calcium in the multivitamin.
- C. Usual activity after taking the multivitamin.
- D. If the multivitamin is taken with a meal or snack
Correct Answer: B
Rationale: Confirming calcium content in the multivitamin ensures adequate intake for bone health, critical for osteoporosis prevention.
An adult client is admitted to the medical unit due to rectal bleeding after a colonoscopy in which a polyp was biopsied and cauterized. Which Intervention should the nurse do first?
- A. Palpate all peripheral pulses in the extremities.
- B. Encourage cough and deep breathing exercises.
- C. Complete a focused assessment of the abdomen.
- D. Initiate measurement of fluid intake and output.
Correct Answer: C
Rationale: A focused abdominal assessment determines the severity of bleeding and guides further interventions, prioritizing over pulses, respiratory exercises, or fluid monitoring.
History and Physical
Nurses' Notes
Orders
Imaging Studies
The client is a young male who appears to be 25 to 30 years old. He was found unconscious on a sidewalk by a jogger who was passing by. The jogger called an ambulance, and the emergency medical technicians (EMTS) transported the client to the hospital. The client is arousable but unable to say what his name is or what happened to him. A STAT head computed tomography (CT) scan in the emergency department showed no abnormalities, so the client will be admitted to the medical floor for observation and further tests.
Exhibits
The nurse comes into the room to replace the IV bag and notices the client's extremities are jerking violently. The client is not arousable and the oxygen saturation is 59% on the monitor.
Based on the information collected, the client is likely experiencing [condition] related to [cause].
- A. Increased intracranial pressure
- B. Brain herniation
- C. Hypoxia
- D. Hypercapnia
- E. Absence seizure
- F. Decorticate posturing
- G. Tonic clonic seizure
Correct Answer: C,F
Rationale: Hypoxia from a tonic-clonic seizure causes low oxygen saturation and jerking movements, requiring urgent intervention.